Spilt blood

Case number:
146

Spilt blood

Author: Caroline Gabias, Jason Barton

This 33 year old man started feeling unwell three weeks prior, with fever, headache, vomiting and slowed thinking. He was admitted to a peripheral hospital a week later with increased headaches, neck stiffness, and persistent vomiting, after having been found unconscious on the bathroom floor. He had a lumbar puncture. A few days after discharge he had two witnessed seizures, was started on phenytoin, and transferred. He had a normal CT angiogram.
After three days he began feeling better, with less neck stiffness and headache, but he noted scotomata in his temporal visual field of each eye. He denied transient visual obscurations or diplopia, but reported pulsatile tinnitus for 2 weeks.

In the past he had migraine and a seizure after mild head trauma 14 years prior.

He had normal acuity and colour vision. Goldmann perimetry is shown. He had metamorphopsia on Amsler grid, temporal to fixation in the left eye. Fundoscopy is shown. Eye movements and neurologic exam was normal. Blood pressure was 129/74mmHg.

Question: What is the diagnosis? Send your answer to us! (Jason Barton)

His fundoscopy shows impressive peripapillary retinal hemorrhages as well as some vitreal hemorrhage (the blurry bits). Despite this, he has only enlarged blind spots on his perimetry.

His lumbar puncture showed lymphocytic pleocytosis with no red cells, and with negative culture and negative viral PCR. After 2 weeks his headache, neck stiffness and pulsatile tinnitus began to improve. Tests showed no evidence of a coagulopathy.

Terson’s syndrome is an intra-ocular hemorrhage (vitreal, pre-retinal or retinal) with subarachnoid hemorrhage (1). It is not from migration of blood from the subarachnoid space, as originally suggested, but from the sudden marked increase in intracranial pressure causing elevation of retinal venous pressure with subsequent vein rupture. It confers a higher mortality in this setting.

Meningitis is usually associated with increased intracranial pressure as well, but this increase is not usually as abrupt as with subarachnoid hemorrhage, and so it is more likely to be associated with papilledema rather than retinal hemorrhage. However, retinal hemorrhages have been rarely reported with meningitis from pneumococcus and Hemophilus influenzae (2,3). This man’s course is consistent with a viral meningitis, complicated by a seizure.